April 1, 2014Volume 78, Number 4Administrative Update: Where Have You Gone Marcus Welby?Daniel J. Cole, M.D., ASA First Vice President

It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change. – Leon C. Megginson

“Marcus Welby, M.D.” was a top-rated television show during the 1970s. I recall Dr. Welby as a wise and caring physician whose clear mission in life was to help another human being in his or her hour of need. However, Dr. Welby was also a nonconformist who often went out on a limb – he was a “system” unto himself.

The health care environment is much different today than it was four decades ago. Uncertainty and volatility are prevalent, and medicine is transforming at warp speed. Individualized care based on interpretation of the best evidence and intuitive decision-making is being replaced by disease-based protocols and standardization. Medical decisions are coerced by quality and cost metrics, and “shared decision-making” and “distributive leadership” are the new buzzwords. Has Marcus Welby become a remnant of the past?

History is littered with organizations that hunkered down within deeply ingrained structures and systems that once delivered transient value to society and their target customer but failed to innovate to stay at the frontier of value, differentiate themselves from competitors and provide the best fit to societal needs (Figure 1), e.g., Kodak, Blockbuster, Blackberry. The corollary is organizations that used innovation and invested in new advantages to maintain value and relevance, e.g., Fuji, Netflix, Apple.

Figure 1: The competitive advantage life cycle. The dashed line represents what occurs over time when an organization fails to innovate or reconfigure. The solid line represents what occurs when an organization innovates in order to provide the best fit to meet the needs of society and hence gains a competitive advantage and maintains relevance.

Specific to anesthesiology, will our profession continue to be defined by an induction to emergence paradigm, or will anesthesiology lead in the transformation of medicine? In the words of Edward de Bona: “Removing the faults in a stagecoach may produce the perfect stagecoach, but it is unlikely to produce the first motor car.”

We live in a tsunami of change. Specific to our specialty, external drivers of change include:

Disruptive public policy, a.k.a., the Affordable Care Act.

Increases in employment of anesthesiologists by health systems or mega-corporations.

Record levels of practice acquisition and consolidation with formation of mega-groups.

Disruptive technology.

Alternative models of payment and the linkage of payment to quality metrics.

Fundamental changes in the health care delivery system.

In a rapidly changing health care landscape, it is critical that we be proactive in defining our relevance where value is created – over the cycle of care of a patient’s condition.

In October 2013, the ASA House of Delegates approved the development of a strategic priority for our specialty – the Perioperative Surgical Home (PSH) model of care. The PSH is an innovative model for delivering patient care during the entire patient surgical/procedural experience, from the time of the decision for surgery until the patient has recovered and returned to the care of his or her patient-centered medical home or primary care provider. The key feature of the PSH is coordination of care throughout all the clinical microsystems of care (Figure 2). Heretofore, in many instances, care was neither integrated nor coordinated between the clinical microsystems, potentially compromising quality and safety over the entire patient experience of care.

Figure 2: The component microsystems of a patient’s surgical/procedural experience.

The strategic goals of the PSH include:

1. To improve the quality and safety of perioperative care;

2. To reduce the cost of health care;

3. To enhance the patient’s experience of care;

4. To strategically position the specialty of anesthesiology within the new framework of health care; and

5. To align with alternative models of payment.

The PSH is an anesthesiologist-led, team-based model of coordinated care that embeds the following strategic principles to achieve its goals.

1. Patient-centered:

- Shared decision-making.

- Patient engagement.

2. Evidenced-based care is implemented, as appropriate, to reduce unexplained variability and complications. It is recognized that patients with co-morbidities presenting for complex surgical procedures are often unpredictable in their clinical manifestation, requiring deviation from standardized clinical pathways.

3. Patient safety is embedded as a patient expectation throughout the entire episode of care.

ASA is committed to forward thinking and proactively doing what is necessary to advance our specialty and keep us at the pinnacle of quality and safety.

As we develop the concept of the surgical home and ramp up the implementation of this new paradigm of health care, it should be clear that “one size will not fit all.” Some practices may determine that their best fit at the local level is to maintain their scope of work within the confines of an induction to emergence paradigm. Some practices may be “all in” and determine that implementing the comprehensive PSH is their future. However, many practices will likely choose an intermediate plan that incrementally adds selected activities that strategically complement their current practice. Development of the PSH model of care should empower each practice with capabilities that provide “best fit” at the local level, creating a future of relevance for their practice and the specialty.

America is searching for high-quality, safe, affordable, physician-led health care. Anesthesiology has a rich heritage of innovating at the quality and safety frontier. But our work is not done. We have an opportunity to enhance our specialty and continue our work at the quality frontier, to diffuse our competencies in patient safety beyond an induction to emergence paradigm and lead in the fight against what has now been reported as the third-leading cause of death in the United States (preventable harm).

Marcus Welby is not dead. That wise and caring physician whose clear mission in life was to help another human being in his or her hour of need continues to be our raison d’être. The paradigm within which we work will undoubtedly change, but our purpose will live on.

We should consider the words of Clayton Christensen: “You may hate gravity, but gravity doesn’t care.” That is, health care will undoubtedly change, and we should seize the opportunity to be proactive and create our future.

Daniel J. Cole, M.D. is Professor of Clinical Anesthesiology, Department of Anesthesiology & Perioperative Medicine, and Vice Chair for Professional and Business Development, David Geffen School of Medicine, University of California, Los Angeles.